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Asthma among older adults in Massachusetts: Using surveillance data
to prompt action Kathleen Fitzsimmons, MPH
Asthma Prevention and Control ProgramMassachusetts Department of Public Health
2011 CSTE Annual ConferencePittsburgh, PA
June 2011
Overview
• Background– Asthma – Older Adults – Priority population in MA
• Data Analysis– Purpose– Findings
• Taking Action– Potential Partners– Next Steps
Asthma
• Chronic inflammatory disease of the airways– Symptoms: wheezing, shortness of breath, chest tightness, cough– Cause of individual cases usually unknown– No cure exists, but can be controlled
• Affects all ages– US (2008): 7.3% of adults (16.4 mil), 9.4% of children (7.0 mil)– Of adults with asthma, 15.9% aged 65+
• Estimated $20.7 billion annual healthcare expenditures (NHLBI, 2009)
Asthma Prevention and Control Program
Our Mission: To improve the quality of life for all MA residents with asthma and to reduce disparities in asthma outcomes.
Selected Key Activities:• Asthma Surveillance• Partnering to implement the state asthma plan and
coordinate asthma prevention and control activities throughout the state, region and country
Surveillance:Burden of Asthma in Massachusetts
• Asthma prevalence in Massachusetts is among the highest in the nation –approximately 10% of adults and children have asthma.
• Disparities in poor asthma outcomes exist. – Children aged 0-4– Adults aged 65 and older– Black, Non-Hispanics and
Hispanics
Population of Adults Aged ≥ 65, United States, 1900-2050
Source: Federal Interagency Forum on Aging-Related Statistics, http://www.agingstats.gov
Background - Older Adults and Asthma
• Asthma in older adults is under-diagnosed and under-treated (Stupka E & deShazo, 2009)
• Diagnosis and management of asthma in older adults may pose unique challenges (NAEPP, 1996)
• Considerable knowledge gaps – epidemiology and effectiveness of interventions (NAEPP, 1996)
Partnering: Strategic Plan for Asthma in Massachusetts
GOAL 1 – Enhance Surveillance
GOAL 2 – Improve Asthma Management for Massachusetts Residents
•Identify specific “priority” populationsthat have significant disparate outcomes
• Prepare data bulletins to explain and document the burden of asthma among priority populations, such as older adults
• Asthma and Allergy Foundation of America –New England Chapter and MDPH will facilitate the development of state-specific recommendations for public health and healthcare institutions to improve asthma outcomes for older adults
• MDPH will promote and support dissemination of the recommendations
Special Topic Data Bulletin:Highlights
• Prevalence
• Characteristics of Older Adults with Asthma
• Asthma Treatment Guidelines
• Hospitalizations
• Mortality
Asthma PrevalenceData Source: Behavioral Risk Factor Surveillance System (BRFSS)
BRFSS: Lifetime and Current Asthma
• “Have you ever been told by a doctor, nurse, or other health professional that you had asthma?”
• “Do you still have asthma?”
Prevalence of Current Asthma among Adults Aged ≥ 65 , MA and US, 2000-2009
0.0
2.0
4.0
6.0
8.0
10.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Prev
alen
ce (%
)
US Curr
MA Curr
Data Source: Behavioral Risk Factor Surveillance System, 2000-2009
7.5
8.4
Current Asthma Prevalence among Adults Aged ≥ 65 in Massachusetts
Data Source: MA Behavioral Risk Factor Surveillance System, 2007-2009
Compared to…Higher among…
Those not (6.2% & 7.2%, respectively)
Those overweight (10.0%) or obese (13.5%)
Those without (6.5%)Those with a disability (14.1%)
Those with household incomes of $75,000+ (7.4%)
Those with household incomes of < $25,000 (10.4%)
Those with 4+ years of college (6.9%)
Those with < high school degree (11.4%)
White, Non-Hispanics (8.4%)Hispanics (12.6%)
Males (6.4%)Females (10.2%)
Those aged 80+ (6.5%)Those aged 65-79 (9.5%)
Characteristics of Older Adults with Asthma
Data Source: BRFSS Adult Asthma Call-back Survey
Asthma Call-Back Survey
Methodology:• Eligible: ‘Yes’ in BRFSS to
ever diagnosed with asthma
• Asked if willing to participate in a follow-up interview
• Called within 2 weeks & administered the Asthma Call-Back Survey
Content:• History of asthma symptoms• Health care utilization• Asthma education• Home environment• Medications• Access to care• Workplace• Co-morbid conditions• Complimentary and
alternative therapy
http://www.cdc.gov/asthma/questions.htm#callback
37.7
58.4 63.1
19.5
75.9
25.3
56.0
29.9
82.6
0.010.020.030.040.050.060.070.080.090.0
Very poor contro
l
Symptoms, past
mo.
Limite
d usual
activitie
s, past
yr.
Sleep disr
upted, past
mo.
Rescue m
eds, p
ast 3 m
os.
Unsched
uled office v
isit, p
ast yr.
COPD diagnosis
Depressi
on diagnosisDiag
nosed as a
dult
Characteristic
Perc
ent (
%)
Characteristics of Massachusetts Adults Aged
≥ 65 with Asthma
Data Source: 2006-2008 BRFSS Adult Asthma Call-Back Survey
Asthma Treatment GuidelinesData Sources: BRFSS & BRFSS Adult Asthma Call-back Survey
NAEPP Guidelines
Persons with asthma should have 2 + visits/yr with their healthcare provider (HCP) for routine
asthma care.
In Massachusetts
• 47.3% of older adults with asthma reported having the recommended number of routine visits in past year.
• 14.6% reported one visit.
• 38.1% reported no visits.
– HP2020: None (Developmental)
Persons with asthma should have an Asthma Action Plan.
In Massachusetts
• 24.6% of older adults with asthma reported ever having been given an Asthma Action Plan by a HCP.
– HP2020: 36.8%
Older adults with asthma should receive influenza vaccination annually and pneumococcal vaccination per recommended schedule.
In Massachusetts
• 81.1% of older adults with asthma reported having influenza vaccination in past year.
– HP2020 (all adults ≥ 65): 90%
• 84.1%% reported ever having pneumococcal vaccination.
– HP2020 (all adults ≥ 65): 90%
Persons with asthma should receive education about appropriate response to an asthma episode, including recognizing early signs
and symptoms or monitoring peak flow results.
In Massachusetts
• 58.0% of older adults were taught how to recognize early signs and symptoms of an attack.
• 69.1% were taught by a HCP what to do in response to an asthma attack.
• 46.7% were taught how to use a peak flow meter to adjust daily medications
– HP2020(combined): 68.5%
Persons with asthma should have a discussion with their HCP about environmental exposures
at home and work.
In Massachusetts
• 33.7% of older adults with asthma advised by HCP to change aspects of home or work to improve asthma.
– HP2020: 54.5%
• 31.0% reported believed their asthma was caused or made worse by any job they’d ever had, but only 7.7% reported discussing it with a HCP.
– HP2020: None (Developmental)
Smoking or exposure to tobacco smoke should be avoided.
In Massachusetts
• 6.2% of older adults with asthma were characterized as current smokers.
– HP2020 (all adults): 12.0%
• In addition, 7.4% of never or former smokers reported exposure to environmental tobacco smoke at home in the past week.
Asthma HospitalizationsData Source: Massachusetts Inpatient Hospitalization Discharge Database
Asthma Hospitalizations among Older Adults in Massachusetts
• 23.2% of the ~9,725 asthma hospitalizations each year among aged ≥ 65
• 44% occurred January-April
• Compared to adults aged 18-64:– Longer avg. length of stay (4.6 vs. 3.5 days)– Higher mean total charge ($12,745 vs. $10,368)
• Medicare expected payer for 90%
Data Source: MA: 2006-2008 Massachusetts Inpatient Hospital Discharge Database
17.6 17.3 18.0
22.1 23.326.2 26.2
24.527.6
0.0
5.0
10.0
15.0
20.0
25.0
30.0
2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Hos
pita
lizat
ions
per
10,
000
Res
iden
ts
MA
Rate of Hospitalization for Asthma among Adults Aged ≥ 65 , MA, 2000-2008
Data Source: MA: 2000-2008 Massachusetts Inpatient Hospital Discharge Database; US: 2000-2006 National Hospital Discharge Survey
HP2020 (20.3)
Rate of Hospitalization for Asthma among Adults Aged ≥ 65 by Sex, MA, 2000-2008
11.2 10.2 11.014.6 16.0
17.5 18.9 18.121.421.8 22.1 22.7
27.2 28.3
32.1 31.328.8
31.8
0
5
10
15
20
25
30
35
2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Hos
pita
lizat
ions
per
10,
000
Res
iden
ts
Males Females
Data Source: MA: 2000-2008 Massachusetts Inpatient Hospital Discharge Database
HP2020
Asthma MortalityData Source: Massachusetts Registry of Vital Records and Statistics
Asthma Mortality Rate by Age, MA, 2000-2007
6.6
4.54.9
4.3
5.3 5.4
3.6 3.5
0.9 0.8 0.8 0.7 0.6 0.7 0.4 0.3
0
1
2
3
4
5
6
7
2000 2001 2002 2003 2004 2005 2006 2007
Year
Dea
ths
per 1
00,0
00 R
esid
ents
0-64 65+
Data Source: 2000-2007 Massachusetts Registry of Vital Records and Statistics.
HP2020 (2.3)
Summary
• Asthma prevalence among adults aged ≥ 65 - increasing nationally & in MA.
• Asthma hospitalization rate among older MA adults – 2nd highest of any age group & increasing; the rate for younger adults has been consistently lower & stable.
• 327 older MA adults died from asthma between 2000-2007; accounted for over half of the asthma deaths during this time.
• Asthma mortality rate for older MA adults has consistently been higher than the rate for younger ages.
• Among older MA adults, females and Hispanics bear a disproportionate asthma burden.
• MA has not yet reached HP2020 targets for asthma management or outcomes in this age group.
Taking Action – Potential Partners
• MDPH Office of Healthy Aging • MDPH Chronic Disease Self Management Program • State/Local Councils On Aging & Senior Centers• State/Local Elder Affairs Offices• Healthcare Providers• MCPHS Pharmacy Outreach Program• AARP• Home Care Alliance of Mass.• LeadingAge Mass. • Mass. Assisted Living Facilities Association• Mass. Council for Home Care Aide Services • Mass. Senior Action Council, Inc. • LGBT Aging Project
Taking Action – Next Steps
• Share findings
• Convene Task Force– Identify & evaluate effective interventions for addressing
asthma in older adults– Identify areas where more research is needed
• Develop recommendations
• Disseminate recommendations
Acknowledgements
• Jean Zotter• Carrie Huisingh• Tish Davis• Maria McKenna• Kathleen Grattan• Vivian Pun• Elise Pechter• James West• Jamie Wilkins
• Cheryl Bartlett• Jewel Mullen• MDPH Internal Asthma
Working Group• Joshua Nyambose• Sheila Erimez• Elaine Rosenberg• David Callahan• Kathie Sunnarborg
*This work was supported by the CDC Cooperative Agreement #5U59EH000502-02. Contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.
Contact Info
Kathleen Fitzsimmons, MPH
Epidemiologist
(617) 624-5624
Asthma Prevention and Control Program
Massachusetts Department of Public Health
250 Washington Street
Boston, MA 02108
http://www.mass.gov/dph/asthma
Jean Zotter, JD
Director
(617) 994-9807
